“primary problems” of c.p.: the “primary problems” · demographics • 24 males, 11 females...

Cerebral Palsy: Surgical Treatmentof the Upper Extremity

ANN E. VAN HEEST, MD

UNIVERSITY OF MINNESOTA

GILLETTE CHILDREN’S HOSPITAL

SHRINER’S HOSPITAL-TWIN CITIES

AACPDM Annual Meeting ICL 2015

OBJECTIVES

• ETIOLOGY

• PATIENT EVALUATION

• TREATMENT OPTIONS

“Primary Problems” of C.P.:

•Problems with equilibrium

•Loss of selective motor control

•Abnormal tone /spasticity

•“Weakness”

•Impaired sensation

The “Primary Problems”• Generally, not remediable

The “Secondary Problems”

•JOINT MALPOSITIONING

•MUSCLE IMBALANCE

•FUNCTIONAL IMPAIRMENT

The “Secondary Problems”

•Generally, remediable by a variety of methods •therapy, splints, medications, surgery

“Tertiary Problems”

• Skeletal Deformity

• Joint Contracture• Muscle Contracture

“Tertiary Problems” of C.P.

•Prevention by early intervention•Operative salvage procedures

Ann E. Van Heest, M.D.

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MOTOR HOMUNCULUS

The Cerebral Cortex of Man, Penfield & Rassmussen 1950

• CP

• CVA

• TBI

C. P. MANIFESTATIONS

• SHOULDER INTERNALLY ROTATED

• ELBOW FLEXED

• FOREARM PRONATED

• WRIST FLEXED

• THUMB-IN-PALM

PATIENT EVALUATION

• PROM

• Joint contracture, muscle contracture

JOINT vs MUSCLE CONTRACTURE

• FINGER FLEXORS ARE BI-ARTICULAR MUSCLES

• WRIST POSITION AFFECTS FINGER POSITION IF FINGER FLEXOR MUSCLE CONTRACTURE

Volkmannn’s Angle

PATIENT EVALUATION

• PROM

• Joint contracture, muscle contracture

• AROM

• Patterns of muscle activity

• SPASTIC

• FLACCID

• ATHETOID

MUSCLE MOVEMENT ASSESSMENT

C.P. Disease Specific ASSESSMENT TOOLS• House Upper Extremity Use (JBJS 1981)• Manual Skills Assessment Classification (Dev Med

Child Neurol 2006)• Shriner’s Hospital Upper Extremity Evaluation

(Davids JBJS 2005)• Video Analysis (Waters J Hand Surg 2004, Carlson

J Hand Surg)• Melbourne Analysis of Unilateral Limb (Dev Med

Child Neurol 2001)• Motion Lab Analysis (VanHeest Hand Clinics 2003)• Assistive Hand Assessment (Krumlinde-Sundholm,

Develop Med & Child Neuro 2007)

VIDEO TAPE ANALYSIS OF ADL’S

• OBSERVE ARM POSITIONING IN SPACE

• Carlson et al JHandSurg 2007

• Pre-surgical plan

• Video analysis

• 72% changed surgical plan after video review


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Use of Motion Lab to assess muscle spasticity vs phasic control

“TOOLS OF THE TRADE”

• Soft-tissue Releases

• Tendon Transfers

• Bone/Joint Stabilization

Common CP Deformities

• ELBOW: Flexion

• FOREARM: Pronation

• WRIST: Flexion-Ulnar deviation

• THUMB: In-the-Palm

• FINGERS: Swan-neckFlexor tightness

`

Soft-tissue Releases Biceps lengthening

Brachialis lengthening

ELBOW FLEXION DEFORMITY

Biceps and Brachialis Lengthening

Soft-tissue Releases Pronator Teres release

Tendon Transfers Pronator Teres re-routing

PRONATION DEFORMITY


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Pronator teres release

Soft-tissue Releases FCR lengtheningFCU lengthening

Flexor pronator slide

Tendon Transfers ECU to ECRB/L

FCU to ECRB/L (Green transfer)BR to ECRB/L

Contraindicated: FCR to ECRB/LP. Teres to ECRL

Joint Stabilization Wrist fusion with PRCPRC

WRIST FLEXION DEFORMITY

SPASTIC CONTRACTED MUSCLE

VOLITIONAL CONTROL MUSCLE

FCU to ECRB transfer (Green transfer)Green and Banks, JBJS. 44A, 1962

Wrist flexion deformity

FCU to ECRB

• Incision

• FCU exposure


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Mobilize to allow for muscle excursion Tensioning

Neutral position at rest

Post-operative Result: FCU to ECRBSoft-tissue Releases FCR lengthening

FCU lengthening






WRIST FLEXION DEFORMITY

• Union• 41/42 wrists united

• Wrist Position• Preop: Max passive ext 28 deg

of flexion

• Postop: 5 deg of extension

• Mean change: 40 deg

• Finger deformities• Swan Neck: 3 hands

• Thumb in palm: 7 hands

• Finger flexor tightness: 21 hands

Indications for Wrist Fusion

• Severe joint contracture

• Poor Hygiene

• Difficulty with daily care acitivities

• Cosmesis

• Poor function

• Poor sensibility

• Poor volitional control


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Demographics

• 24 males, 11 females

• Average age at surgery: 21 years (14-50)

• Average follow-up 13 months (1-70)

• CP: 21 triplegia, 14 quadriplegia

• CP: 33 spastic, 2 mixed tone

• Pre-op functional use: House scale 0.5 (range 0-2)

Subjective Visual Analog Scale

No Change

DJD and Carpal Tunnel Syndrome Complications

• Complication Rate 5 wrists (12%)

• Fractures: 4 wrists (10%)• 3pts fractured at proximal screw holes

• 1 pt fractured at distal screw hole

• Nonunion: 1 wrist

91% fusion, improved wrist positionSoft-tissue Releases FCR lengthening

FCU lengthening






Summary: WRIST FLEXION DEFORMITY

SPASTIC CONTRACTED MUSCLE

PHASIC CONTROLLED MUSCLE

NO DIGITAL CONTROL

Soft-tissue Releases

Tendon Transfers

Bone/Joint Stabilization

THUMB IN PALM DEFORMITYSTEP 1: RELEASE OF CONTRACTURES


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ADDUCTOR RELEASE

Matev I. Surgical treatment of spastic"thumb-in-palm" deformity.

J Bone Joint Surg [Br], 1963;45:703-708

Thumb Muscle Function:Flexion-Adduction vs Abduction-Extension

Release Tight Structures Augment Weak Structures

EPL Re-routing to 1st Dorsal Compartment

Thumb as ABductorThumb as ADductor

Manske, Hand Clinics, 1990

Skeletal Joint Stabilization

• MCP Fusion

• MCP Joint Capsulodesis

SURGICAL OUTCOMES

• House,J. Van Heest, A. Cariello, C. Surgical Treatment of the Upper Extremityin Cerebral Palsy J. Hand Surgery 24A, 323-330, 1999

• 134 Patients: age 4-37 (Ave=14years)

• Male=79 : Female=55• 180 Operations with

718 Procedures• 4 Procedures/operation

OUTCOME: Functional Use ScoresLevel0 Does not use1 Poor passive assist2 Fair passive assist3 Good passive assist 4 Poor active assist5 Fair active assist6 Good active assist7 Partial spontaneous use8 Spontaneous use

JBJS 63A:216-225, 1981

Pre-operative Average 2.3

Post-operative Average 5.0ImprovementAverage 2.6

OUTCOME: Predictive Factors

Functional Activity Level

• CP Type p=0.09

• Intelligence p=0.40

• Stereognosis p=0.51

• Two-point discrimination p=0.49

• Voluntary Control p=0.039


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Disclosure• Clinical Outcomes

Studies Advisory Board Grant, Shriners Hospital for Children

• Multi-center Study– Northern California

– Twin Cities

– Greenville

– Intermountain

– Shreveport

– Tampa

– Chicago

• No other Disclosures

Hypothesis

For children with upper extremity cerebral palsy who meet standard clinical indications for tendon transfer, those who receive surgical treatment would have greater improvement in function than either children receiving botulinum toxin injections, or children receiving regular ongoing treatment, as measured by validated appropriate assessment tools.

Materials and Methods

• Surgery (P. teres release, FCU to ECRB tendon transfer, thumb adductor release, EPL re-routing)

• Botulinum toxin injections (10u/kg max, P. teres, FCU, thumb adductor, 3 injections)

• Regular Ongoing Therapy (standardized protocol)

• Comparison at Pre- vs 12 months Post of 3 treatment groups (ANOVA, p,0.05)

FIRST TESTING (PRE-TREATMENT)

Botulinum Toxin Group 2nd injections(3 months)

Botulinum Toxin Group 1st injections-FCU-PT-Adductor

Surgery Group-FCU to ECRB-PT release-thumb adductor release, -EPL re-routing

Cast for 4 weeks

8 SESSIONS OF SUPERVISED OCCUPATIONAL THERAPY FOLLOWED BY HOME THERAPY PROGRAM

Regular On-going Treatment Group

SECOND TESTINGBotulinum Toxin Group (4.5 months)

Surgery & Regular Ongoing Treatment Groups (6 months)

Botulinum Toxin Group 3rd injections (6 months)

FINAL TESTING 12 months

WHO Definition of Disability

• Bodily Impairment– Grip, Pinch Strength, Stereognosis, VAS, AROM

• Activity Limitation– SHUEE, Box and Blocks, AHA

• Participation Restriction– PODCI, PedsQL (CP module), CAPE, COPM

SHUEE Dynamic Positional Analysis

SH

UE

E D

PA

Sco

re

p-values above columns are from paired “t” tests

p<0.001

p=0.18 p=0.77

surgery vs. botulinum: p=0.001, vs. therapy: p<0.001.

CONCLUSION: Those children receiving surgical treatment showed significantly greater

improvement

• Bodily Impairment– Grip, Pinch Strength, VAS (Parent), AROM (Supination ,

Wrist Ext , Wrist Flex )

• Activity Limitation– SHUEE DPA, Box and Blocks, AHA

• Participation Restriction– PODCI (UE,Transfers, Global scales) PedsQL (CP

movement, eating), CAPE, COPM (satisfaction)


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For Hemiplegic Children meeting standard indications for surgical treatment

• Tendon Transfer Surgery in Upper Extremity Cerebral Palsy Is More Effective than Botulinum Toxin Injections or Regular Ongoing Therapy

• Based on our findings, the authors of this study no longer recommend Botulinum toxin injections

• This study did not provide evidence against therapeutic modalities as maintenance treatments, and we continue to recommend them.

SELF


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“primary problems” of c.p.: the “primary problems” · demographics • 24 males, 11 females...

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